Insurance. Vision plan. Aaaargh.

The BBQ Pit
1

First, there was this: The fun saga of the lying optometrist and me getting more contact lenses. He lied and said my old type of lenses weren’t available; he tried to force me to order them through him; he refused to write a prescription for more than a year; he possibly committed insurance fraud; he was generally unpleasant. I finally got my prescription from him and ordered my lenses online, as I always did, for $40 less per box than he quoted me. Because my eyes are screwed up, the lenses are still expensive. I filed an insurance claim.

Which was just rejected.

Why?

Because the optometrist ordered lenses for me. After I explicitly told them not to.

And why did they do that? My father - who’s insurance it is - called them to ask.

Because the null-brained insurance company has some idiotic sweetheart deal with their optometrists. If the optometrist says your corrective lenses are “medically necessary”, insurance will cover lenses and exams in full - but only if the optometrist orders the lenses. I can’t buy my own ‘medically necessary’ lenses from my preferred retailer if I want insurance to cover any of the cost. Now, try with me to follow this “logic” here: If the doctor didn’t order the lenses himself, then I would have to pay both for the lenses in full, and the doctor’s visit in full.

Why? Oh, I don’t know. Possibly so that patients get accustomed to having their lenses ordered for them at an obscene markup, and consequently never think of going anyplace but the overpriced, couldn’t even cut it as an ophthalmologist and probably got their degree from some 3rd-world correspondence course optometrist jackass?

Or maybe it’s just because why the hell would an insurance company want to give someone - who ostensibly needs corrective lenses - any choice? You need this so you’ll just bend over and take it however the hell we serve it out, you peon!

Is there anything whatsoever in the 20-some-page PDF file of benefit details explaining this? No. Is there anything, anywhere on the insurance website saying this? No. Is there, as far as I’m aware, anything in writing, anywhere, warning the consumer about this? Nope.

So now I’m out $120 bucks. Oh, and did the optometrist’s office ever call me to say “Hey we ordered you lenses any way and now they’re here?” No. Were they reasonable when I called and asked if they could possibly pop them in the mail to me, rather than me finding time between classes and work to ride my bike across town to pick them up? Hah, that’s a nice thought, isn’t it?

Now excuse me, I’m off to contemplate finding the insurance company’s headquarters, and also the relative merits of arson.

2

Sorry to be obtuse, but I don’t get it. Why didn’t you just do it the way it was designed so that your insurance would cover it?

3

Because it should cost less the other way. And of course, like all my experiences with insurance, even if you call beforehand, they won’t / can’t tell you what they will cover beforehand.

4

If Ninjachick needs toric lenses, that means she has an astigmatism. Speaking from experience, different brands of toric lenses feel different on my eyes and it takes a couple of tries to find the right ones.

The lenses offered by the doctor may not have been comfortable, so she had to find her preferred brand online.

5

Yeah, I really do understand all that, but I don’t understand why any of it is the insurance company’s fault. There must be a legal avenue of redress if her doctor has committed fraud or malpractice, and I’ll cheer her on while she pursues it. But the insurance company did what it was supposed to do, unless it was insuring her comfort.

6

Because I didn’t know that the doctor had to order them for insurance to cover the lenses. There is absolutely nothing in any of the paperwork saying so. When I ordered the lenses, I thought I had a $100 allowance towards lenses. The doctor said that my lenses were $75/box*; that doesn’t go very far. So I got my prescription from him and ordered them online for $35/box.

It was only when my insurance claim was denied did I find out that if the doctor claims the lenses to be “medically necessary”, then the doctor has to order the lenses. Again, there is nothing in any of the description of benefits that says this, and I get the impression that the doctors office didn’t even realize it until the insurance company contacted them**. Regardless, no one at any point gave me any indication that the doctor needed to order the lenses. That’s why I’m pissed off: if you’re going to take the choice away from the consumer, you should at least tell them so.

*This was the first brand he prescribed. I’ve been wearing a different brand for years and prefer them, because they are A) more comfortable and B) much cheaper.
**Which sounds a bit suspicious, since I’ve been told that the provider I’m with also is who state and federal lab employees are with, and there’s a lot of them in the Santa Fe area.

ETA:

This too, kind of. Short version: Doctor told me the lenses I’ve been wearing all along had been discontinued and gave me a different type. They were tolerable but not as comfortable. Only after a follow-up did I discover that they do still make my original type of lenses. Doctor really didn’t want to change my prescription to the original type.

7

I am sorry this happened to you. There is no excuse whatsoever for this man lying to you about your lenses having expired.

As for the year-long prescription, well, i’m not a currently practicing optometrist and don’t know the specifics. However, the rationale for this that I have heard is that contact lense use carries risks and that it’s generally a good idea to see how things are going with the lenses after a year, at which point the prescription can be renewed (or not.)

Ninjachick posted:

I actually re-registered to this board just to post a response to this statement. I’m currently a first-year Optometry student. The people in my class are all incredibly bright and motivated, from what I have seen so far. They have taken the same pre-med courses as those would-be doctors and dentists (organic chem, bio, physics etc) and have had to prove their competency in these subjects on a nation-wide admission test. After this, they go to an Optometry school for four years after college. This adds up to 8 years of higher education. Additionally, 25-30% will do a residency afterwards.

This is how one becomes an optometrist in the United States. Maybe it was different decades ago, but nowadays that is the path. The people in my class are not doing this because they were “unable to cut it as an ophthalmologist.” I’m sure they all have their own reasons, but they all seem genuinely interested in Optometry as a profession.

We take an Ethics class that basically talks about not doing some of the things you’ve mentioned. I understand you’re upset with this guy, but keep in mind that you have met one member of the profession, and one that certainly doesn’t represent the optometrists I know.

8

You stated in the other thread that the doctor had put it down as medically necessary, and tried to pass it of as he was doing you a favor. Isn’t it amazing that when this is done your insurance will only pay up if he orders the lens. I think he knew what your insurance company would do, and handled it this way to be sure you bought the lenses from him.

9

We have a winnah!

10

This may sound sarcastic, and that’s not my intention, but when you say “any of the paperwork”, are you including the policy? I mention this only because a lot of people (especially young people) mistakenly assume that everything important is spelled out in the brochures and handouts. But it’s the policy itself that spells out things like this.

If it is indeed the case that the policy does not say this, and the insurance company has just made something up to deny your claim, then you should contact your state’s Attorney General. They just love eating up insurance companies, and you may get your money back.

11

Vision insurance isn’t my strongest piece, but I know a fair amount about it.

(caveat: I didn’t read the entire prior thread…just the entries on this thread)

Your issue can be broken down into a few sections:

  1. Why did the insurance company make me pay out-of-pocket (OOP) for my personally-ordered lenses?

Liberalimplied most of this one. Typically, your benefits are described in detail in a document called a Summary Plan Description (aka “SPD”). That document is usually the source of truth for all benefit decisions, including this type of issue. There is the chance that not ALL procedural concepts are listed within, but the high-level stuff is in there.

  1. Why does the insurance company mandate that my Optometrist order the contacts, as opposed to letting me get them myself?

Part of the mandate of an insurance company is to deliver benefits at a competitive price. This generally allows these companies to make a profit and answer to shareholders (or policyowners, in the case of a Mutual company). To keep costs down, insurance companies often institute “gatekeeper” policies, which have experts act as secondary decision-makers. In your case, it’s very likely that the insurance company requires the doctors to validate medical necessity. Another poster mentioned that contacts are “reviewed” every year for the purposes of medical necessity. This is likely one of the main reasons.

  1. Why couldn’t the doctor prescribe the “older” version of my Toric lense?

It may have something to do with the Vision provider’s (or Vision insurance company) relationship with the contact lense vendor. There may be a contractual mandate in place to prescribe the newest version of an appropriate lense, as long as it’s workable for the employee. There are also “standard of care” provisions which mandate using newer technology if it’s been tested and found to be markedly better than the current crop of treatment.

I know it’s all confusing, and doesn’t always work out perfectly.

-Cem

12

<nitpick>

Actually, contact the Department of Insurance. The Director Of Insurance wil contact the AG office if litigation is necessary.

-Cem

13

Yep, I read the entire thing. Here’s most of what it’s got to say about contact lenses:

There’s nothing in there about “Your doctor needs to order the lenses for you.”

I don’t doubt that there’s some contract between the manufacturer and the doctor. But if the patient says “I greatly prefer the fit of Type A of lenses to Type B, and Type A are much more affordable, could you please prescribe me Type A?”, the doctor has an obligation: either explain why Type A is not medically suitable, or prescribe Type A.

14

My vision insurance just changed to a new plan- and it’s got a sneaky provision I’ve never heard of before. My benefits are split- there’s an eye exam benefit and a benefit for glasses or contact lenses. I don’t have to get the exam and the glasses at the same place- but I do have to use both parts of the benefit on the same day. The information is in the documents I received- but not in the section that describes the benefits.

15

I never had good vision coverage, so I finally said “screw this hassle” and had laser vision correction.

Best thing I have ever done for myself.

:cool:

16

As soon as I have the money and can find a doc to do it, I’m there. Previously I was too young, now I’m too broke, but someday. I haven’t found anyone willing to consider the other options (the overnight lenses that reshape your eyes so you don’t need to wear them during the day allegedly wouldn’t work for me, and I can’t find anyone willing to prescribe extended-wear lenses. “It would simplify my life so much!” say I. “Oh ho, but you might get an infection! OMG!!!11” says the doc.)
Grumble grumble. For that matter - I wear contacts mostly because it’s the only way my vision can get close to 20/20. Everyone told me how much more convienent I’d find it when I made the switch from glasses. Bah, I say. Those people clearly don’t require toric lenses, which spontaneously decide to take a spin around your eye and bork up your vision for a couple minutes. Nor do they have eyes as sensitive as me: it took a few months for me to find solution that didn’t result in daily pain and irritation*. Then they discontinued it because it apparently made people go blind. Again, I finally found another solution that was comfortable. Then they discontinued it because it apparently made people go blind.

Really, I could just save myself so much trouble by gouging my eyes out.

*Full disclosure: my ophthalmologist who first prescribed the contacts also prescribed some sort of anti-allergy drops or something to use daily. But they stung really badly for a minute or two, and were expensive, and I can’t stand putting eye drops in no matter what they are, and I can never keep to a medication schedule (attention span of a goldfish), so the first bottle that should have lasted a month lasted something like six months, at which point it expired and I said, “Ah, screw this, they weren’t helping much anyway.”

17

Ok, so what this is saying to me is that you are either allowed to get:

a) “Medically Necessary” contacts for $10 (to you) and $unknown large amount to your insurance (in which case you also get a 15% discount off your examination)

OR

b) “Elective” contacts for $105 to your insurance, and $whatever else it costs to you.

It sounds like the reason the insurance company refused you, then, is because it got BOTH an “elective contacts” request (from you) and a “medically necessary” request (form the doctor) and it had (presumably) already processed the doc’s paperwork.

So I’d definitely lay this all at the optometrist’s door - he’s the one that has screwed you here.

Thoughts that occur to me:

Did you actually GET your 15% examination discount, like it seems you’re meant to?

Also, is the $10 copay per box or per year? Because depending on how long it takes you to get through a box it doesn’t really seem like you’re getting all that good a deal out of the “medically necessary” sleight-of-hand (quite apart from the ethical issues involved.